cortical visual impairment as it education programs (steps ...€¦ · vision & brain injuries...

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MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING

Cortical Visual Impairment as it

Relates to Seating & Mobility

Presented by:

Angie Kiger M.Ed., CTRS, ATP/SMS

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CONFIDENTIAL AND PROPRIETARY Duplication or Distribution Prohibited 9/28/2017

Content Disclosure

• The author and presenter of the Sunrise Training & Education Programs (STEPS) is a full-time employee of Sunrise Medical.

• The content for this webinar was created by:

– Angie Kiger, M.Ed., CTRS, ATP/SMS

• We do not intend to endorse any particular model, brand

of product or manufacturer.

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CEU Information

• All of the STEPS educational presentations have been certified for

Continuing Education Units (CEU) by The MED Group.

• The MED Group has been accredited as an authorized provider by

the International Association for Continuing Education and Training

(IACET).

• This seminar has been awarded 1 contact hours or .1 CEUs by The

MED Group.

• It is the participant’s responsibility to verify CEU validity for state

licensure and/or other entities.

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To Receive CEUs

• In order to be awarded CEUs, the participant must:

– Participate in the entire two hour seminar.

– Complete the entire demographics form, which includes contact

information and the last 4 digits of the participant’s social

security number (SSN).

– Complete the seminar evaluation form.

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Objectives

• Define cortical visual impairment.

• List the common characteristics individuals with CVI present.

• Identify at least 3 considerations to take into account when

conducting a seating and mobility evaluation on a client with CVI.

• List 3 strategies to utilize when teaching a client with CVI to propel a

wheelchair manual and drive a power wheelchair.

Upon completion of this one seminar participants will be able to:

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Words of Wisdom

“Alone we can do so little….together we can do so much.”

- Helen Keller

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What’s your why?

Rafael

• 17 y/o male

• Unrestrained driver in a MVA.

• Ejected from the vehicle.

• Initial presentation in rehab

program Rancho 2.

• No response to visual stimuli.

• Plateaued in therapy.

Maryn

• 2 y/o female

• Dx w/ CVI approximately 6

months-old

• Mitochondrial disease

• H/o seizures

• Moderate bilateral hearing loss


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What’s The Big Deal?

“The first time I saw her sitting in her KidKart I was shocked at how upright she was sitting and how much more engaged she was in her surroundings. It was a wake-up call to her dad and I about how important proper positioning is for Maryn.”

– Kim (Arlington, VA)

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A few things to consider…

• A child’s motor development can be significantly impacted in a

negative way if there is the presence of a visual impairment, because vision provides vital feedback to the vestibular and

proprioceptive systems (Prechtl et al. 2001).

• A common myth related to CVI is that the individual’s vision will

never improve (Tallent, Tallent, & Bush 2012).

• Caregivers and treatment teams may focus primarily on the conditions that are more readily noticed thus inadvertently

overlooking the presence and/or impact of CVI on the client as

related to seating and mobility (Chokron & Dutton 2016).


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A few things to consider…

• “Behaviors that are adaptive to enable the child to cope, or are

reactive owing to the stress caused by certain environments or conditions exceeding mental processing capacity, can resemble a

range of disorders such as ASD and ADHD.”

• “The presence of CVI will induce as a direct consequence, a delay

or a deficit in motor skills, motor coordination, and motor control.”


(Chokron & Dutton 2016).

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Practical Understanding

• What’s involved in catching a ball?

– See it

– Identify it

– Distinguish from other objects

– Choose it

– Predict it’s vector

– Configure and move hand to catch it

• Computing process for vision multi-step process

• How might this relate to mobility?


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The Players


Parent/ Guardian

Teacher/Aide

PT

OT

SLP

RTS

MD

Vision Teacher

Neuro-ophthalm

ologist

Rec. Therapist

Etc.

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General Flow Of The Evaluation

• Explain the purpose and process of the evaluation with the client and caregivers.

• Review goals of the evaluation and case history with the client and caregivers.

• Evaluate the client’s positioning in his/her current seating system and make adjustments/modifications as needed.

• Complete a mat evaluation.

• Equipment trials with the client.

• Review of recommendations

with the client and caregivers.

• Review follow-up plan (i.e.

funding process, dealer

contact information, potential delivery time, etc.)

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Additional Evaluation Considerations

• Screenings, reports, or formal consultation– Physicians (including

specialists)

– Speech Therapist– Teacher - classroom aide

– School therapists – IEP– Audiologist

• Cognition– Ability to following directions – Initiation of exploring the

environment independently

– Visual learner vs. auditory learner (supports needed?)

• Auditory status– Acuity vs. processing

• Communication Status– Verbal vs. non-verbal– Picture based vs. word based

• Vision Status

– Acuity vs. processing

– Field loss, field neglect, color blind, visual motor, etc.

– Cortical visual impairment?


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Visual Acuity

• Clarity and sharpness of vision.

• 20/20 Vision – Term used for normal visual acuity.

– Person can see clearly what should be

seen at 20 feet.

– Does NOT mean perfect vision

• Common Acuity Problems– Myopia - nearsightedness

– Hyperopia - farsightedness

– Astigmatism - can cause images to

appear blurry and stretched out

– Presbyopia – age-related condition in

which items close up become difficult to focus on.

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https://nei.nih.gov/healthyeyes/problems

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Vision & Brain Injuries

• Every person and TBI is unique

• 20-40% of individuals with a TBI experience related visual complications

• 40-50% of the brain is involved in vision

• Visual evaluations post injury– Comprehensive enough?

– Eyes are the collectors and brain is the interpreter

Brain Injuries: Potential Impact on Vision

• Tracking

• Fixation

• Focus Change

• Depth perception

• Peripheral vision

• Binocularity

• Visualization

• Near vision acuity

• Distance acuity

• Vision perception

• Blurred vision

• Sensitivity to light

• Reading difficulties; words

appear to move

• Comprehension difficulty

• Attention and concentration difficulty

• Memory difficulty

• Double vision

• Aching eyes

• Headaches with visual tasks

• Loss of visual field

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CVI Overview

• History

– Late 19th century emergence of the concept that the brain is

involved in vision.

– During WW1 increased knowledge of visual pathways

• Veterans with injuries to the visual cortex could perceive

motion in non-seeing visual fields.

• Became known as “blindsight”

• Blindsight is the awareness of moving targets, lights, and/or colors in the blind area.

– In the 1980’s transition from term cortical blindness to CVI

• Increase in research and dx in children

• Increase in prevalence directly related increase in survival

rate of children with increased survival rates of children who

sustained severe neurological conditions.


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CVI Overview

• CVI Defined

– Brain is unable to process information passed along the visual

pathways.

– Visual impairment due to the result of bilateral damage to the

occipital cortex.

– Can occur congenitally or be acquired.

– Impacts both the Dorsal (“where”) and Ventral (“what”) visual pathways

• CVI has become the primary cause of visual impairment and blindness in children in industrialized countries.


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CVI Evaluation & Diagnosis

• CVI is a brain dysfunction not eye dysfunction

• Often consider a diagnosis of exclusion.

• Cues for Evaluation

– Often have a normal or near normal eye exam

– History or presence of a neurological disorder

– Presence of behavioral responses to visual stimuli unique to CVI

– Sustained gaze may be difficult

– Common presentation: head tilted slightly forward and tilted to the side

• Neuro-ophthalmologist

– Vision problems that are related to the nervous system as opposed the

eyes

• Vision Teacher & Developmental Therapist Vision

– Specialization in CVICONFIDENTIAL AND PROPRIETARY Duplication or Distribution Prohibited 9/28/2017

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CVI Details & Statistics

• Recognized as the primary cause of visual impairment in children in first world countries.

• Largest and fastest growing visual diagnosis.

• Almost ½ of the children diagnosed with a visual impairment have CVI.

• 29% of individuals with CVI also have a cognitive impairment.

• 56% of individuals with CVI also have a additional disabilities


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Medical Conditions Associated With CVI

• O2 deficiency in the brain during or after birth

• Cerebral hemorrhage

• Shunt malfunction

• Hypoglycemia

• Meningitis

• Encephalitis

• Intrauterine infections

• Head injury

• Epilepsy

• Cerebral tumor

• Metabolic conditions


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CVI Common Comorbidities

• Cerebral Palsy

• Cognitive impairment

• Seizure disorder

• Microcephaly

• Hearing loss

• Memory dysfunction

• Hyper or hyposensitivity to sensory stimulation


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CVI Characteristics & Behaviors

• Color Preference

• Movement

• Latency

• Field Preference

• Difficulty with Visual Complexity

• Light Gazing

• Difficulty with Distance Viewing

• Visual Reflexes

• Novelty of Visual Stimuli

• Absence of Visual Reach

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- Dr. Christine Roman-Lantzy

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CVI Characteristics

• Color Preference

– Initially prefer one color

– Commonly red or yellow, but can be others

– High contrast

• Movement

– Movement alerts the brain, especially peripherally

– Attend movement better

– See better when they are moving or object is

moving

– Slight bounce draws attention

– Slow movements


Roman-Lantzy, C. (2007)

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CVI Characteristics

• Latency

– Need for time to process

– Wait time provided in SILENCE

– Up to 20 seconds

• Field Differences

– Rarely visual fields are intact

– Field loss due to brain has potential to develop

– Dictates client position, how stimuli is presented, etc.

– Difficulty noticing items in lower visual fields

– Fear of falling off a cliff



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CVI Characteristics

• Difficulty with Visual Complexity

– Complex patterns

– Complexity of visual array

• Visual crowding

• Busyness

– Complexity of sensory environment

• Touch

• Sound

• Strong olfactory inputs



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CVI Characteristics

• Light Gazing

– Non purposeful gazing

– Attracted to light sources

– Use light to attract visual attention

– Need more light to visually attend.

• Difficulty with Distance Viewing

– May present like nearsighted

– Closer the item is brought to eye less of a chance for visual clutter.

– Look & locate

– How might this impact w/c skills

training?



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CVI Characteristics

• Visual Reflexes

– Absent or delayed blink on response to non-

threatening stimuli

– Atypical response a visual threat - doesn't

blink or try to avoid a moving threat

• Novelty of Visual Stimuli

– Anti-novelty response when presented w/

something new

– Favorite toys or objects

– Decrease visual white noise



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CVI Characteristics

• Absence of Visual Reach

– Look toward an object.

– Look away.

– Then reach for the object



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Improvement/Resolution of Characteristics

• Best chance for resolution is within first 3 years

• Characteristics will not resolve without structured intervention

• Order of Resolution

– Early resolution: light gazing, and visual reflexive response of

blink

– Mid-Resolution: color, latency, visual novelty, visual reflexive response of blink to threat, and movement

– Later Resolution: visual fields, visual motor, complexity, and

distance vision


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CVI Ranges

• Range 1-2

– May localize

– No appropriate fixation on objects or faces

– Consistently attentive to lights or perhaps ceiling fans

– Prolonged periods of latency in visual tasks

– Responds only in strictly controlled environments

– Objects viewed are a single color

– Objects viewed have movement and/or shiny or reflective properties

– Visually attends in near space only

– No blink in response to touch or visual threat

– No regard of the human face



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CVI Ranges

• Ranges 3-4

– Visually fixates when the environment is controlled

– Less attracted to lights; can be redirected

– Latency slightly decreases after periods of consistent viewing

– May look at novel objects if they share characteristics of familiar objects

– Blinks in response to touch and/or visual threat, but the responses may

be latent and/or inconsistent

– Has a favorite color ‣ Shows strong visual field preferences

– May notice moving objects at 2 to 3 feet

– Look and touch completed as separate events



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CVI Ranges

• Range 5-6

– Objects viewed may have two to three colors

– Light is no longer a distracter

– Latency present only when the student is tired, stressed, or overstimulated

– Movement continues to be an important factor for

visual attention

– Student tolerates low levels of background noise

– Blink response to touch is consistently present

– Blink response to visual threat is intermittently present

– Visual attention now extents beyond near space, up to 4 to 6 feet

– May regard familiar faces when voice does not

compete



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CVI Ranges

• Range 7-8

– Selection of toys or objects is less restricted, requires 1 - 2 sessions of "warm up"

– Competing auditory stimuli tolerated during periods of viewing; student may now maintain visual attention on objects that produce music

– Blink response to visual threat consistently present

– Latency rarely present

– Visual attention extends to 10-feet with targets that produce movement

– Movement not required for attention at near distance

– Smiles at/regards familiar and new faces

– May enjoy regarding self in mirror

– Most high-contrast colors and/or familiar patterns regarded

– Simple books, picture cards, or symbols regarded



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CVI Ranges

• Ranges 9-10

– Selection of toys or objects not restricted

– Only the most complex environments affect visual response

– Latency resolved

– No color or pattern preferences

– Visual attention extends beyond 20 feet

– Views books or other two-dimensional materials, simple images

– Uses vision to imitate actions

– Demonstrates memory of visual events

– Displays typical visual-social responses

– Visual fields unrestricted

– Look and reach completed as a single action

– Attends to two-dimensional images against complex backgrounds



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CVI Phases Defined

• Phase 1: Building Visual Behavior

� Color – Will only look at one color items. Exhibits clear favorite

colors.

� Movement – Looks at movement or shiny items. Does not seem interested in non-moving visual stimuli.

� Latency – Long delay before turning to visual stimuli.

� Field Preference – Primarily see stimuli in the peripheral fields.

Little to no response to when stimuli is in central vision position.


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CVI Phases Defined

• Phase I: Building Visual Behavior

� Field Complexity – Rarely looks at faces, sees best in quiet and

uncluttered places.

� Light Gazing – Briefly fixates on lights.

� Distance Viewing – Visually attends to near shapes only.

� Reflexes – Little to no response to visual threat.

� Novelty – Only looks at familiar objects.

� Visual Reach – Look and touch occur separately.


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CVI Phases Defined

• Phase II: Integrating Vision with Function

� Color – Objects can be 2-3 colors with favorite included.

� Movement – Continues to benefit from movement for visual

attention.

� Latency – Delay in looking decreases unless fatigued or ill.

� Field Preference – Visual fields gradually increasing.

� Field Complexity – Emerging attention to faces, patterns, and simple pictures.


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CVI Phases Defined

• Phase III: Resolution of CVI Characteristics

� Light Gazing – No longer fixates on lights.

� Distance Viewing – Visually attends to near shapes only.

� Reflexes – Threat and touch reflex in tact.

� Novelty – Visually explores new items.

� Visual Reach – Intact


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CVI & Wheelchair Provision Thoughts

• Vision is involved in approximately 90% of the learning

process.

• Allowing an individual to be positioned in a seating system best that accommodates visual needs is critical.

• The vision system does not fully develop without

movement.

• Providing independent mobility may help with improving

vision.

• Skills such as depth perception and object avoidance are primarily developed through experience.

• Obtaining the most appropriate seating and wheeled

mobility equipment begins with the evaluation process…

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Evaluation Toolbox

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Outside of the Evaluation Toolbox


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Evaluation Process Strategies


• Setting

– Quiet environment

– Low visual stimulation

– Limited number of teammates in the room at a time

– Familiar caregivers present if possible

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• Personal presentation

– Muted colors and no patterns

– Avoid overpowering scents (perfume, cologne, fabric softener,

cigarettes, mints, etc.)

– Silence phones (not vibrate, silent)


Vs.

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• Approach/Observation

– Prior to approach

• Stand back and watch

• Posture

• Response to stimuli

• Functional activities

– Initial approach

– Transition with caregiver

• Position for vision

• Allow for movement

• Reproducibility

• Familiar toys/activities


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Overall Goals of Wheelchair Seating & Positioning

• Support postural alignment

– Provide balance for function

– Provide base of support for

stability

– Slow down or correct flexible

deformity

– Accommodate fixed deformity

– Optimize functional tone

– Inhibit non functional tone

• Facilitate function

– Activity related functions

– Physiological functions

– Independence

• Increase sitting tolerance

– Consider comfort over time

• Skin care

– Protect skin integrity

– Decrease moisture

– Consider shearing

– Repositioning

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What role does vision play in wheelchair seating & positioning?

Seating Equipment: Examples & Considerations


Out of the box or standard cushions and backs

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Custom fabricated seating


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Positioning Belts

Lateral Supports

Headrests

Trays


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Dynamic Components

Wheelchair: Examples & Considerations

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Manual Mobility

Wheelchair: Examples & Considerations

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Power Mobility

Skills Training Ideas

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Resources

• https://strategytosee.com/

• http://www.perkinselearning.org/videos/webcast/cortical-visual-impairment-and-evaluation-functional-vision

• https://cviteacher.wordpress.com/

• http://wvde.state.wv.us/osp/vi/cvi/


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CVI Resources

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Dr. Christine Roman-Lantzy

www.littlebearsees.org

Resources

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www.littlebearsees.org

CRT Industry Resources

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www.resna.org

www.nrrts.orgwww.ncart.us

Final Thoughts

• Evaluation setting

• Inquire about vision – eyes & brain

• Silence is golden

• Observe

• Allow for movements

• Position for vision

• Familiar objects/toys

• Inquire about CVI range

• Involve the team

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MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING

Thank You For Participating!

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cortical visual impairment as it education programs (steps ...€¦ · vision & brain injuries...

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